VRS Referral

You may complete our Referral Form below, or download and return it by email to Referrals@vrsdm.com or by fax to (860) 323-0205.

Download as MS Word Document OR Adobe PDF

Referred By

Insurance Carrier

Treating Physician


Service Requested

Initial Contact


Plaintiff's Attorney

If applicable

Defense Attorney

If applicable
Click or drag a file to this area to upload.

Thank you for your referral. Someone on the VRS Team will be in touch soon to confirm receipt.

If applicable